Filling the Mental Health Gap

May 24, 2013

by Genevieve J. Long

Since their daughter was born, Javier and Marisa* haven’t connected as they used to. After a long day at work, Marisa resents doing all the shopping, cooking, and child care for 10-month-old Nina, who’s into everything. Javier is tired, too. “I need to relax so I can provide for my family the next day,” he says. Nestor, a student therapist at the Lewis & Clark Community Counseling Center, talks with the couple about their problems. Javier joins a men’s group and Marisa a women’s group to learn how gender, family background, social class, and other cultural factors shape their interactions. They watch videos to stimulate discussion of traditional gender roles and consider how power and oppression contribute to their difficulties. The center helps them put their problems in perspective, finding solutions based on strengths such as their work ethic and family connections.

In the recession, funding for many low-cost health clinics has dried up, including mental health resources. Yet a tough economy, job losses, and demographic shifts have only increased the need for affordable mental health care. In January 2012, Lewis & Clark faculty and students stepped in to help fill the gap. The Graduate School of Education and Counseling opened the Lewis & Clark Community Counseling Center on Barbur Boulevard, just a mile from downtown Portland.

The center provides low-cost counseling services to individuals, couples, and families with general mental health issues, relationship problems, or addictions, including gambling problems. All therapists are Lewis & Clark graduate students in the third and last year of one of three counseling programs: addictions, mental health, or marriage, couple, and family therapy. Experienced Lewis & Clark faculty provide live supervision during sessions. Hands-on work with clients is part of most clinical counseling programs, but the close, state-of-the-art mentoring at Lewis & Clark sets this clinic apart. Every treatment room has a live video feed, and group therapy rooms have two-way mirrors to allow supervisors and other students to watch sessions. Faculty can offer guidance through an earpiece the student therapist wears.

Director Antonia Mueller says the intensive nature of training at the Community Counseling Center not only ensures that clients receive top-quality care, but provides trainees with an outstanding learning experience. “There’s an amazing difference between live mentoring and delayed feedback given an hour, or maybe even a week, later.”

Boyd Pidcock, associate professor of counseling psychology and director of Lewis & Clark’s addiction counseling program, says utilizing trainee therapists “allows us to serve clients who may not otherwise have access to mental health services. The natural integration of education and high-quality care allows us to make a long-term, effective commitment to the community. That’s essential because the need is so great.”

Linda King, a case manager with the Portland nonprofit Neighborhood House, says, “Many of our clients have never sought help for mental health or haven’t had the resources to do so. At Lewis & Clark, we can usually schedule them for intake interviews in days rather than weeks or months, and the financial responsibility is reasonable and affordable.”

Social Justice Through Broad Access to Care

In the United States, the high cost of mental health services is the main barrier to treatment. Recent data from the U.S. Substance Abuse and Mental Health Services Administration show that nearly 20 percent of American adults have a mental illness or disorder but just 38 percent of them receive care. Fully 50 percent of Americans with any mental illness cite high cost as the reason for not getting treatment.

Even those fortunate enough to have health insurance may find that their policies do not cover the full cost of treatment or exclude services such as couples or career counseling.

For these reasons, the Community Counseling Center strives to serve members of all Portland-area communities. Services are offered in English and Spanish (currently, there are eight bilingual therapists). Student therapist Julio Iñiguez, who has been active in all aspects of the center since it opened, says bilingual treatment can be especially helpful with Latino immigrant families, in which parents might be more comfortable speaking Spanish during a session while their children prefer English. Immigrants from Asia and Eastern Europe are also an important target population. “We invite clients from all walks of life, especially those who may not seek or have access to good-quality mental health care,” Pidcock says.

In addition to establishing a state-of-the-art training center, Lewis & Clark developed the Community Counseling Center to put its social justice principles into action. “Without action, social justice principles are abstractions,” says Pidcock. “Lewis & Clark is dedicated to action.”

The social justice focus is a draw for students such as Tana Titus. As a prospective student, she was interested in addictions work because of her experiences serving in the military. She says, “When I learned how dedicated Lewis & Clark is to incorporating social justice in teaching and practice, I was sold.”

The new center helps share the load of low-cost Portland providers such as William Temple House and Portland State University’s Community Counseling Clinic. When necessary, these programs refer to each other to find the best match between prospective clients’ needs and available services.

In keeping with its desire to be accessible to the public, the center promotes its services online through community resource sites such as the National Alliance on Mental Illness of Oregon and 211info.org. The second-largest referral source is health care providers and organizations, from Kaiser

Permanente and local doctors to Planned Parenthood, Cascadia Behavioral Healthcare, and the Domestic Violence Resource Center. “Many agencies have longstanding relationships with Lewis & Clark based on years of internships and practicum trainings, so they refer clients with confidence,” says Mueller.

The center also markets itself through community outreach. “When you’re reaching out to marginalized populations, you have to figure out where they go for assistance,” Mueller says. To reach Latino populations, for example, therapists might attend weekend flea markets in Hillsboro, a semirural community west of Portland that is home to many immigrants and migrant workers. There, counselors help with family issues like helping kids use Facebook appropriately or solving practical problems such as activating a phone’s voice mail feature. Such community outreach has led to calls from radio stations and agencies such as Neighborhood House, the Black Parent Initiative, and the Confederated Tribes of Grand Ronde, with which the center shares a building. “We’ve worked to go beyond ‘let’s call each other’ to discussing how we can help meet specific needs,” says Mueller.

Putting Mental Health in (Cultural) Context

Lewis & Clark’s Community Counseling Center is thought to be unique among West Coast training programs in its use of the “cultural context model” of therapy. This approach is another way the center puts its social justice values into action. “We examine how power, privilege, and oppression affect clients, and seek to break open the therapeutic interaction by moving it into a community setting,” explains therapist Iñiguez. Family, couple, and individual therapy are combined and integrated with group work in order to promote collaborative learning and help clients translate concepts discussed in therapy into action with group members. Therapists use media, such as popular films and music, to help clients recognize how gender, race, sexual orientation, and class affect their lives. Examining power and privilege also helps foster equity in relationships.

We examine how power, privilege, and oppression affect clients, and seek to break open the therapeutic interaction by moving it into a community setting. Julio IñiguezStudent therapist

Learning how they fit into sex, race, and class norms empowers clients and creates accountability. Then, they can build on personal strengths to create a more equitable community. For example, a man who discovers the power relations inherent in male-female and husband-wife dynamics learns how he can avoid abusing power in the relationships. A socially marginalized African American woman can tap strength from family and church communities to help fight depression. The cultural context approach potentially effects broad social change, as individual clients assist other group members and reenter their communities with a fresh awareness of their cultural positions and strengths.

Titus explains that from a social justice perspective, the cultural context approach differs from traditional therapy: “We don’t focus on putting clients in diagnostic categories, but on examining where they are in their larger lives.” In addition to helping clients think critically about their cultural contexts, counselors can provide practical help such as career counseling for someone who has recently lost a job.

Lewis & Clark students also participate in the cultural context approach. With each other and their supervisors, they discuss power, privilege, and oppression in their own lives and work together to meet challenges. “Counselors are often isolated in private practice or agencies that limit the number of professional meetings you can attend,” Mueller says. In open discussions with colleagues, Lewis & Clark counseling students create habits of critical consciousness and mutual assistance that will continue in their professional lives and spread to the larger mental health community.

Growing to Serve the Community

After just one year, the Community Counseling Center is already growing. The center is on track to serve more than 500 clients this spring and has opened a new clinic, Lewis & Clark Problem Gambling Services, which operates in the building on Saturdays and Sundays. Services are currently offered in English and Spanish, and are free to all Oregonians affected by problem gambling, including family members, friends, and coworkers.

After the counseling center, developing problem gambling services was a logical step; Lewis & Clark’s addictions program has a long and productive history of working with the state of Oregon on gambling issues. In 2012, Pidcock and Teresa McDowell, professor and chair of counseling psychology, successfully applied for Lewis & Clark to become a state-licensed provider of problem gambling services. They also received a Multnomah County contract that funds graduate assistantships for the Lewis & Clark students who provide the majority of care.

Like the Community Counseling Center, Lewis & Clark Problem Gambling Services strives to help traditionally underserved and at-risk community members. It is the only state-licensed facility providing weekend services.

The ability to add new services is a measure of how Lewis & Clark’s counseling center is thriving. More than 85 Lewis & Clark graduate students are now working there, and full treatment rooms attest to outreach programs’ success. “It’s been huge,” Mueller says. “Just when we think we can ground ourselves a bit, new doors open because of our faculty members’ individual passions and community involvement. We’re constantly discovering new ideas to incorporate and new ways of helping students serve the community.” Precisely how or where the clinic will grow next is not certain, but Mueller says expansion is the next step. For counseling trainees and the Portland community, that can only be a good thing.